目的 探讨食管静脉曲张(EV)对原发性肝癌合并肝硬化患者根治性切除术预后的影响.方法 回顾性分析2001年1月至2010年12月青岛大学医学院附属医院收治的455例原发性肝癌合并肝硬化患者的临床资料和随访结果.61例患者术前影像学检查出现EV为EV组,394例无EV表现的为无EV组,比较两组患者的手术情况及预后.所有患者术后3个月内每月复查1次,以后每3个月复查1次,随访时间截至2012年12月或患者死亡.计量资料或率的比较采用x2检验；Kaplan-Meier法绘制生存曲线,生存率的比较采用Log-rank检验,多因素分析采用COX回归风险模型.结果 患者均行根治性肝切除术,其中行肝切除+贲门周围血管离断术4例,脾切除术18例(包括联合贲门周围血管离断术3例).EV组患者手术切缘距肿瘤距离＜0.5 cm、脾切除、术中出血量≥1000 ml和术中输血患者比例显著多于无EV组,两组比较,差异有统计学意义(x2=7.113,18.209,5.527,14.298,P＜0.05)；而两组肝切除范围＞1段、解剖性肝切除、术中进行入肝血流阻断的患者比例比较,差异无统计学意义(x2=0.591,0.124,1.412,P＞0.05).455例患者中8例发生上消化道出血,患者均无门静脉癌栓存在.EV组和无EV组患者上消化道出血发生率分别为9.84％(6/61)和0.51％(2/394),两组比较,差异有统计学意义(x2=26.611,P＜0.05).患者均获得随访,中位随访时间为39.0个月(3.0～ 136.3个月).455例患者中共有218例死亡,其中EV组死亡37例,无EV组死亡181例.EV组患者因肝癌、肝病和其他原因死亡者所占比例分别为67.57％(25/37)、29.73％ (11/37)和2.70％(1/37),而无EV组患者所占比例分别为86.19％(156/181)、6.63％(12/181)和7.18％(13/181),两组比较,差异有统计学意义(x2=17.780,P ＜0.05).EV组患者根治性切除术后1、2、5、10年生存率分别为85.2％、65.6％、36.7％和15.7％,均低于无EV组患者的91.6％、79.9％、55.4％和35.7％,两组比较,差异有统计学意义(x2=12.517,P＜0.05).EV组患者1、2、5、10年无瘤生存率分别为63.2％、45.9％、22.9％和15.3％,均低于无EV组患者的80.0％、59.5％、39.1％和31.3％,两组比较,差异有统计学意义(x2=8.900,P＜0.05).单因素分析结果显示:伴有EV、术前AFP≥20 μg/L、肝切除范围＞1段、脾切除、术中输血、肿瘤直径＞5 cm、非孤立型肝癌是影响原发性肝癌合并肝硬化患者根治性切除术后预后的危险因素(x2=12.517,5.370,12.711,4.430,7.148,29.616,47.111,P＜0.05).多因素分析结果显示:肿瘤直径＞5 cm和非孤立型肝癌是影响原发性肝癌合并肝硬化患者根治性切除术后的独立危险因素(RR=1.639,2.041,P＜0.05).结论 伴有EV的原发性肝癌合并肝硬化患者根治性切除术的生存时间显著低于无EV的患者,但伴有EV不是影响原发性肝癌合并肝硬化患者根治性切除术后长期生存的独立危险因素.
目的 探討食管靜脈麯張(EV)對原髮性肝癌閤併肝硬化患者根治性切除術預後的影響.方法 迴顧性分析2001年1月至2010年12月青島大學醫學院附屬醫院收治的455例原髮性肝癌閤併肝硬化患者的臨床資料和隨訪結果.61例患者術前影像學檢查齣現EV為EV組,394例無EV錶現的為無EV組,比較兩組患者的手術情況及預後.所有患者術後3箇月內每月複查1次,以後每3箇月複查1次,隨訪時間截至2012年12月或患者死亡.計量資料或率的比較採用x2檢驗；Kaplan-Meier法繪製生存麯線,生存率的比較採用Log-rank檢驗,多因素分析採用COX迴歸風險模型.結果 患者均行根治性肝切除術,其中行肝切除+賁門週圍血管離斷術4例,脾切除術18例(包括聯閤賁門週圍血管離斷術3例).EV組患者手術切緣距腫瘤距離＜0.5 cm、脾切除、術中齣血量≥1000 ml和術中輸血患者比例顯著多于無EV組,兩組比較,差異有統計學意義(x2=7.113,18.209,5.527,14.298,P＜0.05)；而兩組肝切除範圍＞1段、解剖性肝切除、術中進行入肝血流阻斷的患者比例比較,差異無統計學意義(x2=0.591,0.124,1.412,P＞0.05).455例患者中8例髮生上消化道齣血,患者均無門靜脈癌栓存在.EV組和無EV組患者上消化道齣血髮生率分彆為9.84％(6/61)和0.51％(2/394),兩組比較,差異有統計學意義(x2=26.611,P＜0.05).患者均穫得隨訪,中位隨訪時間為39.0箇月(3.0～ 136.3箇月).455例患者中共有218例死亡,其中EV組死亡37例,無EV組死亡181例.EV組患者因肝癌、肝病和其他原因死亡者所佔比例分彆為67.57％(25/37)、29.73％ (11/37)和2.70％(1/37),而無EV組患者所佔比例分彆為86.19％(156/181)、6.63％(12/181)和7.18％(13/181),兩組比較,差異有統計學意義(x2=17.780,P ＜0.05).EV組患者根治性切除術後1、2、5、10年生存率分彆為85.2％、65.6％、36.7％和15.7％,均低于無EV組患者的91.6％、79.9％、55.4％和35.7％,兩組比較,差異有統計學意義(x2=12.517,P＜0.05).EV組患者1、2、5、10年無瘤生存率分彆為63.2％、45.9％、22.9％和15.3％,均低于無EV組患者的80.0％、59.5％、39.1％和31.3％,兩組比較,差異有統計學意義(x2=8.900,P＜0.05).單因素分析結果顯示:伴有EV、術前AFP≥20 μg/L、肝切除範圍＞1段、脾切除、術中輸血、腫瘤直徑＞5 cm、非孤立型肝癌是影響原髮性肝癌閤併肝硬化患者根治性切除術後預後的危險因素(x2=12.517,5.370,12.711,4.430,7.148,29.616,47.111,P＜0.05).多因素分析結果顯示:腫瘤直徑＞5 cm和非孤立型肝癌是影響原髮性肝癌閤併肝硬化患者根治性切除術後的獨立危險因素(RR=1.639,2.041,P＜0.05).結論 伴有EV的原髮性肝癌閤併肝硬化患者根治性切除術的生存時間顯著低于無EV的患者,但伴有EV不是影響原髮性肝癌閤併肝硬化患者根治性切除術後長期生存的獨立危險因素.
목적 탐토식관정맥곡장(EV)대원발성간암합병간경화환자근치성절제술예후적영향.방법 회고성분석2001년1월지2010년12월청도대학의학원부속의원수치적455례원발성간암합병간경화환자적림상자료화수방결과.61례환자술전영상학검사출현EV위EV조,394례무EV표현적위무EV조,비교량조환자적수술정황급예후.소유환자술후3개월내매월복사1차,이후매3개월복사1차,수방시간절지2012년12월혹환자사망.계량자료혹솔적비교채용x2검험；Kaplan-Meier법회제생존곡선,생존솔적비교채용Log-rank검험,다인소분석채용COX회귀풍험모형.결과 환자균행근치성간절제술,기중행간절제+분문주위혈관리단술4례,비절제술18례(포괄연합분문주위혈관리단술3례).EV조환자수술절연거종류거리＜0.5 cm、비절제、술중출혈량≥1000 ml화술중수혈환자비례현저다우무EV조,량조비교,차이유통계학의의(x2=7.113,18.209,5.527,14.298,P＜0.05)；이량조간절제범위＞1단、해부성간절제、술중진행입간혈류조단적환자비례비교,차이무통계학의의(x2=0.591,0.124,1.412,P＞0.05).455례환자중8례발생상소화도출혈,환자균무문정맥암전존재.EV조화무EV조환자상소화도출혈발생솔분별위9.84％(6/61)화0.51％(2/394),량조비교,차이유통계학의의(x2=26.611,P＜0.05).환자균획득수방,중위수방시간위39.0개월(3.0～ 136.3개월).455례환자중공유218례사망,기중EV조사망37례,무EV조사망181례.EV조환자인간암、간병화기타원인사망자소점비례분별위67.57％(25/37)、29.73％ (11/37)화2.70％(1/37),이무EV조환자소점비례분별위86.19％(156/181)、6.63％(12/181)화7.18％(13/181),량조비교,차이유통계학의의(x2=17.780,P ＜0.05).EV조환자근치성절제술후1、2、5、10년생존솔분별위85.2％、65.6％、36.7％화15.7％,균저우무EV조환자적91.6％、79.9％、55.4％화35.7％,량조비교,차이유통계학의의(x2=12.517,P＜0.05).EV조환자1、2、5、10년무류생존솔분별위63.2％、45.9％、22.9％화15.3％,균저우무EV조환자적80.0％、59.5％、39.1％화31.3％,량조비교,차이유통계학의의(x2=8.900,P＜0.05).단인소분석결과현시:반유EV、술전AFP≥20 μg/L、간절제범위＞1단、비절제、술중수혈、종류직경＞5 cm、비고립형간암시영향원발성간암합병간경화환자근치성절제술후예후적위험인소(x2=12.517,5.370,12.711,4.430,7.148,29.616,47.111,P＜0.05).다인소분석결과현시:종류직경＞5 cm화비고립형간암시영향원발성간암합병간경화환자근치성절제술후적독립위험인소(RR=1.639,2.041,P＜0.05).결론 반유EV적원발성간암합병간경화환자근치성절제술적생존시간현저저우무EV적환자,단반유EV불시영향원발성간암합병간경화환자근치성절제술후장기생존적독립위험인소.
Objective To investigate the effects of esophageal varices (EV) on the incidence of complications and prognosis of patients with hepatocellular carcinoma (HCC) and hepatic cirrhosis after radical resection.Methods The clinical data of 455 patients with HCC and hepatic cirrhosis who were admitted to the Affiliated Hospital of Qingdao University from January 2001 to December 2010 were retrospectively analyzed.All the patients were divided into the EV group (61 patients) and non-EV group (394 patients) according to the results of preoperative imaging examination.The intraoperative condition and the prognosis of the patients in the 2 groups were compared.All the patients were re-examined every month within the first 3 months after operation,and then they were re-examined every 3 months thereafter.The follow-up was ended till December,2012 or the day of patients' death.Comparison of the measurement data and rates was done by chi-square test ; the survival curve was drawn by Kaplan-Meier method,and the survival was analyzed using the Log-rank test; multivariate analysis was done by Cox proportional hazard regression model.Results All the patients received radical hepatectomy.Four patients received hepatectomy + pericardial devascularization,18 received hepatectomy + splenectomy (3 of them received pericardial devascularization).The ratios of patients with the distance between the resection margin and the tumor ＜ 0.5 cm,splenectomy,volume of intraoperative blood loss≥ 1000 ml and intraoperative blood transfusion in the EV group were significantly greater than those in the non-EV group (x2=7.113,18.209,5.527,14.298,P＜0.05).There was no significant difference in the ratio of patients who received multi-segmentectomy,anatomical hepatectomy,intraoperative inflow occlusion between the 2 groups (x2 =0.591,0.124,1.412,P ＞ 0.05).Eight patients were complicated with upper gastrointestinal bleeding,while no portal vein tumor thrombus was detected in all the patients.The incidences of upper gastrointestinal bleeding of the EV group and the non-EV group were 9.84％ (6/61) and 0.51％ (2/394),with significant difference between the 2 groups (x2 =26.611,P ＜ 0.05).The median time of follow-up was 39.0 months (range,3.0-136.3 months).There were 218 patients died,including 37 patients in the EV group and 181 in the non-EV group.The ratios of patients died of HCC,hepatic diseases or other reasons were 67.57％ (25/37),29.73％ (11/37) and 2.70％ (1/37) in the EV group,and 86.19％ (156/181),6.63％ (12/181) and 7.18％ (13/181) in the non-EV group,with significant difference between the 2 groups (x2=17.780,P ＜0.05).The 1-,2-,5-,10-year survival rates after radical resection in the EV group were 85.2％,65.6％,36.7％ and 15.7％,which were significantly lower than 91.6％,79.9％,55.4％ and 35.7％ of the non-EV group (x2=12.517,P ＜ 0.05).The 1-,2-,5-,10-year tumor-free survival rates of the EV group were 63.2％,45.9％,22.9％ and 15.3％,which were significantly lower than 80.0％,59.5％,39.1％ and 31.3％ (x2=8.900,P ＜0.05).The results of univariate analysis showed that EV,pre-operative alpha-fetoprotein≥20 μg/L,multi-segmentectomy,splenectomy,intraoperative blood transfusion,tumor diameter ＞ 5 cm,non-solitary tumor were risk factors influencing the prognosis of patients with HCC and hepatic cirrhosis after radical resection (x2=12.517,5.370,12.711,4.430,7.148,29.616,47.111,P ＜ 0.05).The results of multivariate analysis showed that tumor diameter ＞ 5 cm and non-solitary tumor were independent risk factors influencing the prognosis of patients with HCC and hepatic cirrhosis after radical resection (RR =1.639,2.041,P ＜ 0.05).Conclusion The survival time of cirrhotic HCC patients with EV is significantly shorter than those without EV after radical resection,while EV was not the independent risk factor influencing the survival of cirrhotic HCC patients after radical resection.
